Local Boards

SURGICAL SCRUB in Ricardo P. Rodriquez Memorial Hospital, City of San Fernando; Angeles University Foundation Medical Center, Angeles City

Hospital, Municipality/City/Province

Prepared by:

Cayanan, Faith Muñoz

Date Performed Patient's INITIAL (only) SURGICAL PROCEDURE

PERFORMED O.R. Nurse on Duty

(Name and Signature) SUPERVISED BY

Clinical Instructor

Name and Signature

Case Number

12-10-10

91307

A.C.V. Cesarean Section Rosario Padiernos, R.N.

Hydee A. Medina, R.N., M.N.

4-12-11 3619

B.C. Partial Hip Arthroplasty

Venancio Flores, R.N.

Karen David Sembrano, R.N., M.N.

4-14-11

21800

L.C.L. Diverting Colostomy Aries Tiongson, R.N.

Karen David Sembrano, R.N., M.N.

Noted by: Carmelita E. Siroy, R.N., M.A.N.

(Print Name and Signature) Approved by: Zenaida S. Fernandez, R.N., Ph.D.

(Print Name and Signature)

Clinical Coordinator, PRC I.D. No. 0111086 Valid Until: November 06, 2012 Dean, PRC I.D. No. 0070634 Valid Until: August 07, 2012

Date document is signed: ________________ Time: __________________

Please specify Highest Nursing Degree Earned: M.A.N. Date document is signed: _______________ Time: _______

Please specify Highest Nursing Degree Earned: Ph.D.

ANGELES UNIVERSITY FOUNDATION

Mac Arthur Hiway 2009 Angeles City

Tel Nos. +63 (045) 625-2888 local 711/+63 (045) 625-2811, Telefax +63 (045) 625-2809

Website: www.auf.edu.ph Email: con@auf.edu.ph

SURGICAL CIRCULATING in Angeles University Foundation Medical Center, Angeles City

Hospital, Municipality/City/Province

Prepared by:

Cayanan, Faith Muñoz

Date Performed Patient's INITIAL (only) SURGICAL PROCEDURE

PERFORMED O.R. Nurse on Duty

(Name and Signature) SUPERVISED BY

Clinical Instructor

Name and Signature

Case Number

4-12-11

166925

R.M.P. Creation of AV Fistula Raymond D. Yutuc, R.N.

Karen David Sembrano, R.N., M.N.

4-14-11

136570

M.M. Low Segment Cesarean Section I Angelica Penaredondo, R.N.

Karen David Sembrano, R.N., M.N.

10-25-11

141252

N.P.S.

Disarticulation of distal phalanx 4th digit left hand Annette S. Pamplona, R.N.

Deane Joy E. Agoncillo, R.N., M.N.

Noted by: Carmelita E. Siroy, R.N., M.A.N.

(Print Name and Signature) Approved by: Zenaida S. Fernandez, R.N., Ph.D.

(Print Name and Signature)

Clinical Coordinator, PRC I.D. No. 0111086 Valid Until: November 06, 2012 Dean, PRC I.D. No. 0070634 Valid Until: August 07, 2012

Date document is signed: ________________ Time: __________________

Please specify Highest Nursing Degree Earned: M.A.N. Date document is signed: _______________ Time: _______

Please specify Highest Nursing Degree Earned: Ph.D.

ANGELES UNIVERSITY FOUNDATION

Mac Arthur Hiway 2009 Angeles City

Tel Nos. +63 (045) 625-2888 local 711/+63 (045) 625-2811, Telefax +63 (045) 625-2809

Website: www.auf.edu.ph Email: con@auf.edu.ph

ACTUAL DELIVERY in Rafael Lazatin Memorial Medical Center, Angeles City; Angeles University Foundation Medical Center, Angeles City; Jose B. Lingad Memorial Regional Hospital, City of San Fernando

Hospital/Home/Lying-In Clinic, Municipality/City/Province